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Home My WebLink About0275 PINE STREET - Health 275 PINE STREET, A=152-016 1 c Omdord, NO. 1521/3 BLU ;►�� 10% /5a-61(a Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 275 Pine Street " Property Address Jane M. Clinghan Owner Owner's Name information is / + ' required for every West Barnstable t/ MA 02668 October 21, 2016 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important When A. General Information 9�� filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not David D. Flaherty Jr,RS, REHS use the return Name of Inspector key. Flaherty Environmental Services Company Name P.O. Box 81 Company Address Yarmouth Port MA 02675 City/Town State Zip Code 774-994-1166 SI#4713 Telephone Number - License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority October 22, 2016 In Aectoesnature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future.under the same or different conditions of use. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 f 17 �'vj�V s Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 275 Pine Street Property Address Jane M. Clinghan Owner Owner's Name information is required for every West Barnstable MA 02668 October 21, 2016 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old" or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments wM 275 Pine Street Property Address Jane M. Clinghan Owner Owner's Name information is West Barnstable MA 02668 October 21,2016 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 4'M 275 Pine Street Property Address Jane M. Clinghan Owner Owner's Name information is West Barnstable MA 02668 October 21, 2016 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 275 Pine Street Property Address Jane M. Clinghan Owner Owner's Name information is required for every West Barnstable MA 02668 October 21, 2016 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation_ El ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ _ the system is located in a nitrogen sensitive area (interim Wellhead Protection Area—IWPA)or a mapped Zone li of a public water supply well If you have answered"yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface.Sewage Disposal System Form Not for Voluntary Assessments 275 Pine Street Property Address Jane M. Clin han Owner Owner's Name information is MA 02668 October 21, 2016 required for every West Barnstable page. Citylrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? . ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins.doc-rev.6116 TiUe 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts W Tale 5 Official Inspecti on Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 275 Pine Street Property Address Jane M. Clinghan Owner Owner's Name information is required for every West Barnstable MA 02668 October 21, 2016 page. CityrTown State Zip Code Date of Inspection D. System Information Description: 3 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d private well 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ® No current Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 275 Pine Street Property Address Jane M. Clinghan Owner Owner's Name information is West Barnstable MA 02668 October 21, 2016. required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: owner's agent, 5 or 6 years ago Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ;M 275 Pine Street Property Address Jane M. Clinghan Owner Owner's Name information is required for every West Barnstable MA 02668 October 21, 2016 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: unk Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 2.5 Depth below grade:, feet Material of construction: ❑ cast iron. ®40 PVC ❑ other(explain): >100 Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): joints tight venting through dwelling adequate no evidence of leakage Septic Tank(locate on site plan): 2 Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No 1000 gallon H-20 Dimensions: 10.. Sludge depth: t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 275 Pine Street Property Address Jane M. Clinghan Owner Owners Name information is west Barnstable MA 02668 October 21, 2016 required for every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 24" Scum thickness 6" Distance from top of scum to top of outlet tee or baffle 4" 9,. Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? dip stick, tape measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): maintenance pumping should be performed at this time and every two to three years, inlet&outlet tees in good working order, tank seems structurally sound, liquid level is appropriate, no evidence of leakage Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 275 Pine Street M Property Address Jane M. Clibghan Owner Owner's Name information is West Barnstable MA 02668 October 21, 2016 required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 275 Pine Street Property Address Jane M. Clinghan Owner Owner's Name information is required for every West Barnstable MA 02668 October 21, 2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert n/a Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): no dbox encountered Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑.No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working orders stem is a conditional ass. P P 9 � Y P Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: leachpit greater than 4.5' below grade, unable to locate with probe t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form:Not for Voluntary Assessments M 275 Pine Street Property Address Jane M. Clinghan Owner Owner's Name information is required for every West Barnstable MA 02668 October21, 2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: (1) ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): (1)6' x 6' precast leachpit with stone, soils sandy with gravel &cobbles, no signs of hydraulic failure or breakout vegetation typical (lawn) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments' 275 Pine Street Property Address Jane M. Clinghan Owner Owner's Name information is required for every. West Barnstable MA 02668 October 21, 2016 - page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments GSM v<J•v 275 Pine Street Property Address Jane M. Clinghan Owner Owner's Name information is west Barnstable MA 02668 October21, 2016 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately 77 t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °w 275 Pine Street Property Address Jane M. Clinghan - Owner Owner's Name information is MA 02668 October 21, 2016 required for every West Barnstable page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Sha+low wells >20 Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ n Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: abutting pond elevation >20' below leach facility elevation Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form . Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 275 Pine S_reet Property Address Jane M. Clinghan Owner Owner's Name information is West Barnstable MA 02668 October 21, 2016 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 s'- Page. CERTIFICATE OF ANALYSIS b Barnstable County Health Laboratory Report Prepared For: poet 1ted: 1/30/2004 RECEIVED Bryan,Mary-Gail Order Number: G0424043 Mary-Gail Bryan FEB 0 3 2004 275 Pine Street West Barnstable, MA 02668 TOWN OF BARNSTABLE HEALTH DEPT. Laboratory ID#: 0424043-01 Description: Water-Drinking Water Sample#: 24043 Sampling Location: 275 Pine Street West Barnstable MA Collected 1/21/2004 Collected by: M Bryan Received 1/21/2004 Test Parameters ITEM RESULT UNITS MDL MCL Method# Tested LAB: Chemistry Chlorine .02 mg/L, 0.00 EPA 330.5 1/21/2004 Routine ITEM RESULT UNITS MDL MCL Method# Tested LAB:IC Lab c} - - 1 + ,_ Nitrates 0.23 mg/L 0.02 10 463 F s 1/22/2004 ' LAB: Metals Copper 1.2 mg/L 0.1 1.3 SM 3111E 1/26/2004 Iron 0.2 mg/L 0.1 -0.3 SM 311113 1/26/2004 Sodium { 119 mg/L 1.0 20 SM 3111B 1/26/2004 LAB:Microbiology i Total Coliform Absent P/A 0 Absent 309 1/21/2004 LAB:Physical Chemistry Conductance 730 umons/cm 1 EPA 120.1 1/21/2004 p11 6.2 pH-units 0 EPA 150.1 1/21/2004 Note:`_ Sodium level above the average.Those on low sodium diet may wish to contact physician. ,, { Approved �._. (Lab Director) i Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 �TOWN OF B-ARNSTABLE LOCATION�ir , SEWAGE # VILLAGE_ ASSESSOR'S MAP & LOT 01 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) . Feet Furnished by -12. tr 1 i r , r TOWN OF-BARNSTABLE LOCATION 7� P �s 1 A• SEWAGE # ' I VILLAGE ASSESSOR'S MAP &LOT. '' T INSTALLER'S NAME&PHONE NO. I SEPTIC TANK CAPACITY LEACHING FACILITY: (size) .. (type) ( ae) NO. OF BEDROOMS BUILDER OR OWNER PERMITDATE:. ` COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility.(If any wells exist` on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facili ) . r n Feet Furnished by Utz . k h I I I i I� e.I V \ 1 I I I V4 ' TOWN OF BARNSTABLE ff UNDERGROUND FUEL AND CHEMICAL STORAGE SYSTEMS Q pkl-)- f NAME a ADDRESS� VILLAGE Fb St LOCATION OF TANK#: CAPACITY: TYPE OF FUEL AGE: TYPE: OR CHEMICAL (Give same information for any additional tanks on reverse side of card) 4f' /40 DATE OF PURCHASE OF EACH: 1. 2. 3. - 4. DATE OF FIRE DEPARTMENT PERMIT: TESTING CERTIFICATION SUBMITTED: PASSED DID NOT PASS NAME WCATION Clinghan, Wm. J. & Jane M. Pine St. Pine Street W. Barn., MA 02668 West Barnstable, MA 02668 ' BK & PG - DATE GRANTED AMOUNT STORED Under 2,000 gals. 77/165 April 28, 1966 Domestic heating oil. DATE PAID No.---J- —°3------- Fee----'�---- ---- BOARD OF HEALTH TOWN OF BARNSTABLE 0ppYicat ion ArVell Con5tructionPermit Application is hereby made for a permit to Construct ( ), Alter ( ), or Repair (kan individual Well at: Location- Address Assessors Map and Parcel ----------------------------------------- Owner Address ----------- TO---&x-----oop F—,o (rile ��----a."k-w Installer — Driller Address Type of Building Dwelling -- - -- -- -- - ---------------- Other - Type of Building ---- No. of Persons-------------------- --- . Type of Well Wer--- y -e -- --- pla finta --- Capacity---------------------- ---------------------------------------------- Purpose of Well-c --- i.tSe.)1.@.d__4US-e ---------- Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to place the well in operation until a Certificate of Compliance has been issued by the Board of Health. Signed-- ------12 - --� date Application A lication Approved B 6 -25 -9Z) date Application Disapproved for the following reasons:------------------------------------------------------------------------------- date PermitNo.--�' ---------------------- ------�--�-f------------------------------ Issued------------------------- date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of Compliance THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( �r Repaired ( ) by- — -� ' Q/r11f f-x � �- --------------------------------------------------------------------------------------------- Installer has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. Dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE---------------------------------------------------------------------------------- Inspector--------------------------------------------------------------------------------- BOARD OF HEALTH TOWN OF BARNSTABLE 10ell-Con5truct ion Permit No. - -------- Fee- ------- Permission is hereby grantedto Construct ( ), Alter( ), or Repair an Individual Well at: No. ----"-��'�� ham-- "- - � f�7r ----------------- Street as shown on the application for a Well Construction Permit No.- 9-L21------------------------------ ------ Dated------ Board of Health DATE -- -- - -- -- --------------------------------- No.-- -----af----- Fee---a=S' O 0---- BOARD OF HEALTH rf TOWN OF BARNSTABLE TippYitation-for Vell Con5tructlonpermit Application is hereby made for a permit to Construct ( ), Alter ( ), or Repair X)an individual Well at: ` a 7,5- Pine--t�t�-- , _��cz rn �l ab le— Location - - - - ------- -- - — Address Assessors Map and Parcel -PO-BOX-'43 }-1 Guns xble____Dac�� Owner Address -Mee_IN"-- 1'�)r I -"�` - n ' - -P� -&x_-Yoo Fore.sVaiC M/9 oa f yv Installer — Driller Address Type of Building Dwelling----------------------------------------------------------------- bther - Type of Biiiling -' — = R --------- ': a No. of Perso''ns------------------------------------------ ------ "4er— 4'' e 1��e`ne n�f`. Type of Well-- - -_ -p-- ---------------------------------------- YP ---- --- - -- --- - --- Capacity of Well -- ------------ Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation until a Certificate of Compliance has been issued by the Board of Health. Signed--- -- _° a= -6?0 - ~ 6 —.2S to Application Approved By-------------- --------------c 'r�. �-- - - - date Application Disapproved for the following reasons:------------------------------------------------------------------------------------------------- ---- ------- - - ---- - - -- -- date I� PermitNo.- 1d 1-------------------------------------------------- Issued------------------------------------------------------------------------------------- date F BOARD:OF HEALTH TOWN OF BARNSTABLE Certificate ®f Compliance THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ,-,-/Or Repaired ( ) by---- te-4- -- -�€ ��_1�y1_ #7. I.G 1 -------------_---------------------------------------------------------------------------- Installer at-- 7 — —- - - has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. �-2--02-Y-__-_-__-Dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE--------------------------------------------------------------------------------------- Inspector----------------------------------------------------------------------------------- BOARD OF HEALTH ' " TOWN ' OF BAR-NSTABLE Veil Con5truct iori vermit No. =- -r�--------- Fee---= ---—---- Permission is hereby granted------- - - -------- --------------------------------------- to Construct ( ), Alter ( ), or Repair ('�) an Individual Well at: / No. -------`--�--- 4 i -----K7 ---j�=-AV2'&12 r4 ---------------------------------------------------------------------------------------------- Street `+as shown on the application for a Well Construction Permit No.-_! a�- - -------------------------------------------- Dated -- - -- ---------------------------- ---------------- ---------------------------------------------------- Board of Health DATE----------------------------------------------------------------------------------- , 5